In October 1981, 49 employees of a Tennessee hospital,
scheduled
to receive tuberculin skin tests as part of their institution's
tuberculosis-surveillance program, were inadvertently given
Bacillus
of Calmette and Guerin (BCG) instead of purified protein derivative
of
tuberculin (PPD). Of those vaccinated, 47 subsequently developed
the
expected local reaction to BCG at the site of vaccination on the
forearm; 1 employee had no local reaction, and 1 experienced a
local
reaction and axillary lymphadenopathy. All these reactions
resolved
spontaneously. Approximately 10 weeks after receiving BCG, 20 of
the
49 employees returned voluntarily for testing with 5 tuberculin
units
(TU) of PPD; 18 of the 20 (90%) developed "significant" tuberculin
reactions ( greater than or equal to 10 mm in diameter).
During the same month, BCG was also given instead of PPD to 63
residents and 37 employees of a Michigan nursing home. The 3
employees who either were known tuberculin reactors or had a past
history of tuberculosis developed large, erythematous reactions at
the
inoculation site within 2 days of receiving the BCG; 2 of the 3
also
noted low-grade fever that lasted for several days. Five days
after
the BCG was given, the vaccinated residents and other vaccinated
staff
were tuberculin tested. Six employees whose tuberculin tests had
been
negative in the past had "significant" reactions. Of the 63
residents, 3 had "significant" reactions; 2 of these 3 had a record
of
having had negative tuberculin tests in the past. Several weeks
later, 3 patients and 1 staff member were given isoniazid (INH) for
a
short period because of slowly healing ulcers at the site of
inoculation. The medication was discontinued after the lesions
were
examined by a consultant who found them to be typical lesions
developed by persons given BCG.
Reported by HR Anderson, MD, Div of Tuberculosis Control, RH
Hutcheson, Jr, MD, State Epidemiologist, Tennessee State Dept of
Health; W Thar, MD, MPH, Mid-Michigan District Health Dept, NB
Keon,
Div of Disease Surveillance, NS Hayner, MD, MPH, State
Epidemiologist,
Michigan Dept of Health; Tuberculosis Control Div, Center for
Prevention Svcs, CDC.
Editorial Note
Editorial Note: In the United States, tuberculosis-control
programs
for employees, patients, or residents in health-care facilities
should
be based on measures to prevent the transmission of tuberculosis
and
on a program of tuberculin testing of employees at periodic
intervals
to detect any recently acquired infections (1-3).
In the episodes described, 0.1 ml of BCG vaccine was
inadvertently
given instead of the same dose of PPD. Ulceration at the site of
BCG
administration is common and usually heals spontaneously after
several
weeks. Axillary lymphadenopathy may also occur. Resolution is
usually spontaneous, but occasionally treatment is required. Most
strains of BCG are sensitive to antituberculosis drugs.
Disseminated
BCG infection is uncommon, and usually occurs only among
immunologically abnormal hosts.
Inservice education programs can help maintain an awareness of
tuberculosis among health-care personnel, and can help clarify the
distinction between BCG (a tuberculosis vaccine) and PPD (a
tuberculin
skin-test antigen). These episodes, along with previous instances
in
which diphtheria-pertussis-tetanus (DPT) and PPD solutions have
been
inadvertently substituted for one another (4), also reemphasize the
need for personnel to read labels on drugs and biologics carefully
before such materials are used.
References
CDC. Guidelines for prevention of TB transmission in
hospitals.
Atlanta: Center for Disease Control, 1979. (HEW publication
no.
(CDC) 79-8371).
Stead WW. Tuberculosis among elderly persons: an outbreak in a
nursing home. Ann Intern Med 1981;94:606-10.
American Thoracic Society Executive Committee. The tuberculin
skin test. Am Rev Respir Dis 1981;124:356-63.
Graham DR, Dan BB, Bertagnoll P, Dixon RE. Cutaneous
inflammation
caused by inadvertent intradermal administration of DTP instead
of
PPD. Am J Public Health 1981;71:1040-3.
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